Polio and Politics: The Struggle of Polio Eradication in Pakistan and Afghanistan

Photo via Reuters

Sara Medina: Following the recent suspension of polio vaccination campaigns in Afghanistan by the Taliban and the attacks on polio workers in Pakistan, understanding the struggle of these two countries to eradicate this potentially fatal disease is more critical than ever. Their sociopolitical conditions have fostered widespread resentment towards the polio eradication effort, making it difficult to achieve adequate vaccine coverage.  

Poliomyelitis (polio) is a communicable disease that affects the nervous system, primarily in children under the age of 5. While most infected individuals achieve complete recovery, about 1 in 200 cases ends in permanent paralysis. 5-10% of paralysis cases become fatal when breathing muscles are immobilized. 

In the mid-20th century, polio was one of the most feared diseases in the world. Outbreaks were frequent, and over half a million people around the world were killed or paralyzed by polio annually. Following the 1988 launch of the Global Polio Eradication Initiative, a public-private partnership spearheaded by national governments, global incidence of polio decreased by 99%.

The world is on the brink of completely eradicating a disease for the second time in human history, but polio remains endemic in just two countries: Pakistan and Afghanistan. As long as one child is infected, children around the world remain at risk of contracting the virus due to the possibility of global resurgence. 

Why Pakistan and Afghanistan? The answer is rooted in the complex political landscape of these two countries. Pakistan’s illiberal democracy is intermittently plagued by periods of military rule and subverted by Islamist militant groups, and Afghanistan’s totalitarian government is controlled by the Taliban Movement, an Islamist nationalist group imposing harsh interpretation of Islamic law.

Large numbers of Afghan people come and go from Pakistan, unlike any other country that borders Pakistan. This makes polio eradication in both countries crucial to even one country’s success.

Since January, there have been 18 cases of polio in Afghanistan and 24 in Pakistan. This is more than triple the number of cases seen in 2023. Every clinical case of polio indicates anywhere between 100 and 1,000 subclinical cases; that is, asymptomatic carriers of the virus. This is why even a single case of polio is considered an outbreak.  

The most direct consequence of the political instability in the two countries on polio eradication efforts is the propagation of fear and mistrust in the West, placing a strain on nationwide vaccination campaigns. This mistrust is supplemented by Islamic fundamentalist beliefs denying the necessity of vaccines. 

There is no cure for polio, but it can be prevented by immunization, either live-attenuated oral poliovirus vaccine (OPV), which is made from a weakened form of the virus, or inactivated poliovirus vaccine (IPV). In undervaccinated communities, there is a risk that the virus contained in OPV can begin to circulate and increase in strength, as it recently did in the Gaza Strip. Thus, in order for vaccination campaigns to be effective and avoid the development of a vaccine-derived virus, they must reach over 95% of children. 

The United Nations reported on Sep. 16 that the Taliban suspended polio vaccination campaigns across Afghanistan. Rather than conducting door-to-door campaigns, the Taliban proposed shifting efforts to local mosques where families may bring their children to be vaccinated. This shift creates a barrier to immunization and has the potential to set back years of progress towards polio eradication.

In part, this new policy stemmed from the Taliban’s continued denial of women’s rights. Women in Afghanistan are banned from many public places, schooling, and most professions. However, female polio workers are the backbone of the door-to-door campaigns. Though women in healthcare have largely been permitted to work, a local healthcare worker stated that many female polio workers in southern Afghanistan had begun facing restrictions.

Another reason was a concern that vaccination campaigns might reveal the whereabouts of Taliban leaders to foreign adversaries. This concern may partially have arisen from knowledge of a tactic carried out in the region by the United States in 2011. The CIA had recruited a Pakistani doctor, Shakil Afridi, to gather DNA samples from households for intelligence on the location of Osama Bin Laden. Dr. Afridi claimed to be delivering Hepatitis B vaccines door to door. Since then, the White House has banned the use of vaccine campaigns for espionage, but the story has fueled mistrust in the West and in vaccination campaigns across both Pakistan and Afghanistan.

This mistrust, coupled with Islamic fundamentalist beliefs, has contributed to the development and dissemination of several conspiracy theories surrounding the polio vaccine. One popular theory claims that vaccination campaigns aiming to eradicate polio in Pakistan are a ploy orchestrated by the United States and Israel to sterilize Muslims.

On Sep. 9, Pakistan launched a new polio campaign to vaccinate 30 million children, particularly in response to the rise in cases in the past year. The same day, a vehicle transporting officers responsible for protecting polio workers in northwestern Pakistan was bombed. Two days later, gunmen on motorcycles in the same region opened fire on a team of polio workers and their police escorts, killing one officer and one worker.

Though no one claimed responsibility for these attacks, they both occurred in former strongholds of the Pakistani Taliban near the Afghan border. The attacks are symptoms of a larger pattern of resentment towards the polio vaccination campaigns stemming from fear and mistrust circulated by groups like the Taliban. 

Despite setbacks, there has still been some progress: as of Sep. 28, Pakistan’s new vaccination campaign has reached 33 million children, surpassing their goal for the month. The campaign continues to emphasize a coordinated effort among provincial governments, health workers, and law enforcement.

To counter the resistance to vaccination in Pakistan and Afghanistan, campaigns must directly address the conspiracy theories and religious beliefs at the root of this resistance. Large-scale eradication efforts driven by the Global Polio Eradication Initiative (GPEI) must heavily consider how mistrust in the West may hinder their impact. The GPEI offers a framework for this in their 2022-2026 strategy, suggesting the implementation of Community Immunization Committees to allow community members to directly interact with GPEI and play an active role in decision-making. This level of transparency can help debunk false conspiracy theories and promote community-driven understanding of the science behind immunization. The model has proven successful in several cases, such as in Sudan after its recent outbreak of vaccine-derived polio.

A community building model could be implemented in Pakistan, where the government’s national vision for polio is clear despite socially driven opposition. However, in Afghanistan, the government itself is reluctant to accept the importance of polio vaccination. While campaigns could attempt to work directly with communities, the totalitarian rule of the Taliban is unpredictable and absolute.    

The unstable political climates of Pakistan and Afghanistan and resulting hostility towards vaccination campaigns makes polio eradication a unique challenge in the two countries. Analysis and careful confrontation of these complex sociopolitical factors underlying resistance towards polio eradication is critical to success. 

Sara Medina is a sophomore majoring in Global Health and minoring in Government, interested in the impact of world politics on population health. She is from Southborough, Massachusetts.